PHASE II 2017 - 2018 APPLICATION

CONTACT INFORMATION

Agency Name
Tribe(s) Represented
Name of Health Officer or Tribal Health Director
Street Address
City, State, Zip Code
Phone

OFFICIAL CONTACT(CEO, Chairperson, Tribal Administrator)

Name
Work Phone
E-Mail Address

PROJECT LEAD

Name
Work Phone
E-Mail Address

AREA(S) OF FOCUS

Please select the outcome area(s) that your proposed work plan will be focused on (choose all that apply):

___ Reducing commercial tobacco use & exposure
___ Improve physical activity
___ Improve nutrition and/or access to healthy foods
___ Strengthen team based care and community based clinical linkages
___ Increase support forbreastfeeding

A. PROBLEM STATEMENT

  • Describe the top policy, systems, and environment priority areas identified through an existing community health assessment (CHA) and community action plan (CAP).Based on the needs identified in the CHA, what change strategies will you implement to reduce and prevent chronic conditions?
  • What challenges or barriers do you anticipate in implementing change strategies?How will you usepartnerships to maximize impact and overcome the anticipated challenges of your proposed project?

B. WORK PLAN TEMPLATE

  • Complete Attachment A.

C. ORGANIZATIONAL CAPACITY

  • Describe adequate staffing and experience to carry out the project. Include the system and methods for financial reporting, budget management, and administration.
  • Outline who will have day-to-day responsibility for key tasks such as: leadership of the project, monitoring of the project’s on-going progress, preparation of reports, program evaluation, etc.
  • Describeorganization experience with conducting chronic disease-related projects.

D. EVALUATION METHODS

  • Complete Attachment B
  • What are your ACORNS program’s intended activities, strategies, and outcomes? What are your key evaluation questions to measure the performance and success of these activities, strategies, and outcomes?
  • Describe your intended data sources and instruments to demonstrate the effectiveness of your planned activities and strategies. Describe your quantitative (i.e., numerical) and qualitative (e.g., written narrative, photo-voice, images) evaluation methods to analyze collected data.

D. EVALUATION METHODS (continued)

  • How will your ACORNS program apply and share evaluation findings for continuous local program improvement and as part of the ongoing effort to support sustainable community wellness?

BUDGET

CATEGORY / NARRATIVE / AMOUNT REQUESTED
Salary / $
Fringe / $
Supplies / $
Travel / $
Consultant/Contractual / $
Other / $
TOTAL / $

AUTHORIZED SIGNATURE (CEO, Chairperson, Tribal Administrator)

Name (printed)
Signature
Date

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